Reconstruction of Oncologic Sternectomy Defects: Lessons Learned from 60 Cases at a Single Institution

Abstract

Oncologic sternectomy results in complex defects where preoperative planning is paramount to achieve best reconstructive outcomes. Although pectoralis major muscle flap (PMF) is the workhorse for sternal soft tissue coverage, additional flaps can be required. Our purpose is to evaluate defects in which other flaps beside PMF were required to achieve optimal reconstruction.

Methods: A retrospective review of consecutive patients at our institution who underwent reconstruction after sternal tumor resection was performed. Demographics, surgical characteristics, and outcomes were evaluated. Further analysis was performed to identify defect characteristics where additional flaps to PMF were needed to complete reconstruction.

Results: In 11 years, 60 consecutive patients were identified. Mean age was 58 (28-81) years old, with a mean follow-up of 40.6 (12-64) months. The majority were primary sternal tumors (67%) and the mean defect size was 148 cm² (±81). Fourteen (23%) patients presented with postoperative complications, and the 30-day mortality rate was 1.6%. In 19 (32%) cases, additional flaps were required; the most common being the rectus abdominis muscle flaps. Larger thoracic defects (P = 0.011) and resections involving the inferior sternum (P = 0.021) or the skin (P = 0.011) were more likely to require additional flaps.

Conclusions: Reconstruction of oncologic sternal defects requires a multidisciplinary team approach. Larger thoracic defects, particularly those that involve the skin and the inferior sternum, are more likely to require additional flaps for optimal reconstruction.

Fig. 1.

Thoracic defects of the patients. A, Resection involving half of the manubrium and adjacent sternum, clavicle heads, ribs, and cartilages. B, Resection involving all the manubrium and adjacent sternum with bilateral clavicle heads, ribs, and cartilage. C, Resection of half of the sternal body with adjacent unilateral ribs and cartilages. D, Resection of most of the sternal body with bilateral adjacent ribs and cartilages. E, Total sternectomy. F, Total hemisternectomy.

Fig. 2.

Patient with PMF reconstruction. A, A 49-year-old man status postmanubrial and upper sternal resection for chondrosarcoma, rigid fixation, and bone grafts. B, Bilateral PMF reconstruction for coverage of hardware. C, Two-year follow-up of the patient.

Fig. 3.

Patient with ALT flap reconstruction. A, Computerized tomography scan with 3D reconstruction showing chondrosarcoma in the lower sternum of a male patient. B, Intraoperative photograph showing a defect after subtotal sternectomy. C, Patient at 1-year follow-up after free ALT flap reconstruction.

Fig. 4.

Algorithm for management of sternal defects. *Individual flap options may vary depending on defect and patient characteristics.